You’re not alone. Call 988 to connect to the National Suicide and Crisis Lifeline.

Milliman Report Highlights Barriers to Accessing Behavioral Healthcare Services

WASHINGTON, Nov. 20, 2019 /PRNewswire/ — A report from Milliman, Inc. about disparities between physical and behavioral healthcare for both in-network access and provider reimbursement rates underscores NABH’s position that unnecessary barriers continue to deny access to behavioral healthcare for patients who need it.

The Bowman Family Foundation commissioned Milliman to produce Addiction and Mental Health vs. Physical Health: Widening disparities in network use and provider reimbursement, a 140-page report that shows the gap in disparities for employees and their families seeking mental health and addiction treatment versus treatment for physical health conditions widened in 2016 and 2017.

Read more at PR Newswire

 

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CEO Update | 80

2.2 Million Kids Impacted by the Opioid Crisis

2.2 million children experienced neonatal withdrawal, entered foster care, or were addicted to opioids themselves in 2017, according to a new report from the United Hospital Fund. The report found that 54 out of 1,000 children in West Virginia were impacted by the opioid crisis and 20 out of 1,000 children in California.

If the course of the opioid crisis is not changed, the report concluded that by 2030, there will be 4.3 million children affected annually. “Increase the availability of family-based mental health services” was among the proposed strategies to help kids.

New Price Transparency Rule for Hospitals

Today the Centers for Medicare and Medicaid Services (CMS) issued new rules, effective January 2021, requiring facilities to disclose rates negotiated with insurers; what the hospital is willing to accept in cash from a patient, and the minimum and maximum negotiated charges.

NABH commented in September on the proposed changes and questioned CMS’ legal authority to make these changes. Shortly following the rule, the American Hospital Association, the Federation of American Hospitals, Association of American Medical Colleges and the Children’s Hospital Association announced they intend to challenge the new rule in court.

CMS Proposes Regulations on Fiscal Integrity in Medicaid

CMS has proposed a Medicaid Fiscal Accountability Rule (MFAR) that focuses on eliminating impermissible financing arrangements. CMS stated in a press release that the “proposed rule aims to strengthen accountability, increase transparency of Medicaid payments, and improve program integrity to ensure the Medicaid program is sustainable for future generations.”

Singled out in the proposal are “states that generate extra payments for private nursing facilities that enter into arrangements with local governments to bypass tax and donation rules, and the use of a loophole to tax managed care entities 25 times higher for Medicaid business than for similar commercial business.

States can then use that tax revenue to generate additional payments, with no commiserate increase in state spending.” NABH is planning to submit comments on the proposal.

White House Meeting on “Addressing Overdose and Response at Colleges and Universities”

Sarah Wattenberg, NABH Director of Quality and Addiction Services, moderated a panel at the White House Office of National Drug Control Policy’s meeting, ‘Addressing Overdose and Response at Colleges and Universities.’

The panel focused on federal privacy laws that operate on campuses, which protect students’ privacy but will allow campus officials to inform parents and others when necessary. Panelists included HHS Assistant Secretary for Mental Health and Substance Use, Elinore F. McCance-Katz M.D. P.H.D, who spoke about the prevalence of mental health and substance use on campuses, and clarified that the substance abuse confidentiality law (42 CFR Part 2) did not typically apply to campus health care.

Deputy Assistant Secretary for Higher Education Programs, Chris McCaghren, from the Department of Education, discussed how the Family Educational Rights and Privacy Act (FERPA) applies to student education and treatment records. He emphasized the importance of training all staff on how the law worked.

CMS Issues Final OTP Rule

CMS issued the final regulation on the CY2020 Physician Fee Schedule, which included detailed information about Medicare Enrollment for Opioid Treatment Programs (OTPs). OTPs that enroll may begin billing January 2020. NABH released an NABH Analysis that provides a summary of those provisions, which provide for the treatment of opioid use disorders with new bundled service codes for OTPs, and for telehealth and opioid use treatment services in office-based settings.

Senate Hearing on Alzheimer’s Awareness

NABH PAC Champions Senators Patrick Toomey (R-PA) and Debbie Stabenow (D-MI) will be holding a hearing next week on Alzheimer’s Disease. Witnesses for the hearing include Jason Karlawish, MD the Co-Director of the Penn Memory Center University of Pennsylvania; Janet Tomcavage, Chief Nursing Executive at Geisinger; Marc A. Cohen, Ph.D, Professor Research Director at the Center For Consumer Engagement In Health Innovation UMass Boston and Community Catalyst; and Lauren Kovach, and Alzheimer’s advocate from Brighton , MI.

Register Today for the 2020 NABH Annual Meeting!

Please visit NABH’s Annual Meeting homepage today to view the Schedule At-a-Glance and to register for the meeting.

Also please be sure to make your hotel reservation at the Mandarin Oriental Washington, DC from March 16-18, 2020. We look forward to seeing you next March!

Fact of the Week

The opioid crisis has contributed to the decline in U.S. overall life expectancy for 3 consecutive years; the first 3 year-on-year decline in U.S. life expectancy since the 1918 flu pandemic.

For questions or comments about the Nov. 15 edition of CEO Update, please contact Scott Dziengelski.

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CEO Update | 79

CMS Finalizes OTP Provisions in 2020 Physician Fee Schedule

The Centers for Medicare & Medicaid Services (CMS) finalized provisions for the nation’s opioid treatment programs (OTPs) in the 2020 Physician Fee Schedule regulation that the agency released on Nov. 1.

NABH released an NABH Analysis that provides a summary of those provisions, which provide for the treatment of opioid use disorders with new bundled service codes for OTPs, and for telehealth and opioid use treatment services in office-based settings.

The final rule will be published in the Federal Register on Nov. 15.

CMS Releases Guidance on IMDs Providing Treatment to Medicaid Beneficiaries with AT Lease One SUD

CMS this week released guidance to state Medicaid directors that clarifies how section 5052 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act permits institutions for mental diseases (IMDs) to provide treatment to Medicaid beneficiaries with at least one substance use disorder (SUD).

NABH released an NABH Issue Brief that summarizes the following five key areas that the CMS guidance focuses on: requirement for beneficiaries, requirements for IMDs, requirements for states, maintenance of effort, and interaction with existing IMD policies.

CDC Says Efforts to Prevent Adverse Childhood Experiences Could Potentially Prevent Adult Chronic Conditions

A new Vital Signs report from the Centers for Disease Control and Prevention (CDC) this week found that efforts to prevent adverse childhood experiences could also potentially prevent adult chronic conditions, depression, health risk behaviors, and negative socioeconomic outcomes.

According to the CDC, nearly one in six adults in the study population (15.6 percent) reported four or more types of adverse childhood experiences, which were significantly associated with poorer health outcomes, health risk behavioral, and socioeconomic challenges. Meanwhile, nearly 61 percent of adults experienced at least one adverse childhood experience.

Women, American Indian/Alaska Native, blacks, and the racial/ethnic group categorized as “Other” were more likely to experience four or more types of adverse childhood experiences than were men and whites, the report noted. In addition, younger adults reported exposure to more adverse childhood experience types than did other adults, particularly those aged 65 or older.

“States can use comprehensive public health approaches derived from the best available evidence to prevent childhood adversity before it begins,” the Vital Signs report said. “By creating the conditions for healthy communities and focusing on primary prevention, it is possible to reduce risk for adverse childhood experiences while also mitigating consequences for those already affected by these experiences.”

JAMA Reports Cost-Sharing from Out-of-Network Care Among Those with Behavioral Health Conditions was Higher than Payments for Physical Conditions 

A study in JAMA this week reported that cost-sharing from out-of-network (OON) care among people with behavioral health conditions was significantly higher than for those with other prevalent chronic physical conditions.

Researchers analyzed a large commercial claims database from 2012 to 2017 that included adults with mental health conditions, with alcohol disorders, with drug use disorders, with congestive heart failure, and with diabetes who were between the ages of 18 and 64 and enrolled in employer-sponsored insurance plans.

“Although the parity law has improved access to OON care for patients covered by private insurance, obtaining care from OON providers can come with a price,” the study noted. “Steeper cost-sharing payments, such as higher deductibles and higher coinsurance rates, are typically required for care from OON providers,” it continued. “Although the maximum annual out-of-pocket cost-sharing in private plans is capped under the Patient Protection and Affordable Care Act, this cap applies only to in-network healthcare.”

World Congress to Host Opioid Management Summit in February 

SAMHSA is accepting applications for fiscal year 2020 Promoting Integration of Primary and Behavioral Healthcare (PIPHC) grants until Tuesday, Dec. 10.

The program’s purpose is to promote full integration and collaboration in clinical practice between primary and behavioral healthcare, support integrated care models and improve the overall wellness and health of adults with serious mental illness or children with serious emotional disturbance, and promote and offer integrated care services related to screening, diagnosis, prevention, and treatment of mental and substance use disorders and co-occurring physical health conditions and chronic diseases.

Political Analyst Nathan Gonzales to Address Attendees at NABH Annual Meeting Luncheon 

NABH is pleased to announce Nathan Gonzales, editor and publisher of Inside Elections with Nathan L. Gonzales—which provides non-partisan analysis of U.S. political campaigns—will serve as the 2020 Annual Meeting Luncheon speaker.

Members can learn more about Mr. Gonzales and NABH’s other featured speakers—folk singer Judy Collins and neuroscientist and psychiatrist Tom Insel—in the Speakers section of our Annual Meeting homepage.

Please visit NABH’s Annual Meeting homepage today to register for the meeting and make your hotel reservation at the Mandarin Oriental Washington, DC from March 16-18, 2020.
 
We look forward to seeing you next March!

Fact of the Week

The journal Pediatrics reports that 20 percent of U.S. children live in counties without a child psychiatrist.

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NABH Analysis: OTP Provisions in 2020 Physician Fee Schedule

OTP Provisions in 2020 Physician Fee Schedule

CMS finalized provisions for the nation’s opioid treatment programs (OTPs) in the 2020 Physician Fee Schedule regulation that the agency released on Nov. 1.

This NABH Analysis provides a summary of those provisions, which provide for the treatment of opioid use disorders (OUDs) with new bundled service codes for OTPs, and for telehealth and opioid use treatment services in office-based settings. The final rule will be published in the Federal Register on Nov. 15.

The regulations implement requirements that were included in last year’s Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patient and Communities (SUPPORT) Act. NABH is pleased that the final rule addressed the following issues that NABH mentioned in its comment letter on Sept. 28:

  • CMS raised the non-drug bundle to 161.71, which aligns with NABH’s valuation. We used a building block methodology to demonstrate that the proposed non-drug bundle, based on the CMS PFS rates, was undervalued by 31-48 percent.
  • We also identified a range of indirect and direct services routinely performed by OTPs that CMS included in the final bundle.
  • NABH advocated for the elimination of the partial bundle and recommended a more gradual overall implementation of elements of the proposed rule. In the final rule, CMS temporarily eliminated the partial episode of care with the intent to engage in future rulemaking to more gradually phase in their bundled approach.
  • Comments and data were provided to CMS reflecting potential destabilization of the workforce relevant to the proposed service requirements. CMS addressed these issues through deference to state laws and scopes of service provisions, and a reduction of the number of services needed to bill the bundle.
  • In explanatory text, CMS made note of the NABH recommendation for a rural add-on rate of 17 percent and indicated it may be considered in future rulemaking to incentivize rural care.
  • NABH recommended consideration to permanently set a zero co-pay, and CMS indicated the intent to address the issue in future rulemaking.
  • We advocated to remove OTPs from the high-risk category. CMS finalized a compromise proposal that moves OTPs that have been fully and continuously certified by SAMSA since October 23, 2018 to moderate risk, while maintaining those without full and continuous certification in the high-level risk category, as they are newly-recognized Medicare providers.
  • NABH-supported telehealth codes were finalized.

 
Final Rule Highlights:

Opioid Treatment Programs

  • Definition of OUD Treatment Services
    • FDA-approved opioid agonist and antagonist treatment medications
    • Dispensing and administering of such medications (if applicable)
    • Substance use counseling
    • Individual and group therapy
    • Toxicology testing (both presumptive and definitive testing)
    • Intake activities
    • Periodic assessments
  • Bundled Rates/Episode of Care
    • Bundles reflect a weekly episode of care with no time limits.
    • Rates are a combination of a drug and non-drug component.
    • Full and partial episode construction was finalized to eliminate of partial episodes of care. Utilization will be monitored, intent is to create a partial bundle in the future.
    • One service must be furnished within a week to bill a weekly drug or non-drug bundle.
  • Drug component reflects drug dispensing/administration services; rates vary according to the specific drug (methadone-oral, buprenorphine-oral, buprenorphine-injection, buprenorphine-implant, naltrexone injection), and includes buprenorphine-only products.
    • Maintenance dosage and calculation for oral buprenorphine was increased from 10 mg to 16 mg daily.
    • Created an NOS code for new medications.
  • Non-drug component includes counseling, psychotherapy, toxicology testing and tracks with SAMHSA certification.
    • Does not require counseling and psychotherapy but defers to medical need and state laws relevant to scopes of practice.
    • Case/care management is not included as a bundled or add-on code. Intent to collaborate with OTPs to better understand services, with potential future rulemaking.
    • Rates were increased using building block methodology that values the services based on established Medicare PFS (non-facility) rates for similar services; the Medicare Clinical Laboratory Fee Schedule (CLFS); and state Medicaid programs.
    • Bundles include payment for presumptive and definitive drug testing, with no separate billing under CLFS. There is no add-on code in order to avoid incentive to test more frequently than needed.
  • Add-ons
    • Intake activities for new patients, including a physical examination
    • Periodic assessments during an episode of care, such as for pregnant or postpartum patients
    • Take homes for methadone/buprenorphine for up to 7 days of medication
    • Counseling 30-minutes when counseling or therapy substantially exceed the amount in the individual treatment plan

PFS Bundles for Office-based Services/Telehealth

  • Bundled Rates/Episode of Care
    • Codes for three new (monthly) OUD treatment bundles have been added to the telehealth list on a Category 1 basis for care coordination, individual and group therapy, and counseling through two-way interactive audio-video communication technology.
      • G2086, 70-minute psychotherapy, first month. Includes treatment planning, care coordination, individual and group psychotherapy and counseling
      • G2087, 60-minute psychotherapy, subsequent months. Includes care coordination individual and group psychotherapy and counseling
      • G2088, for each additional 30-minute service required beyond 120 minutes. Includes care coordination, individual and group psychotherapy, and counseling
    • To bill G2086 and G2087, one psychotherapy services must be furnished.
    • If no therapy is provided, the bundle may not be billed. Instead, existing CPT codes for care management 99484, 99492, 99493, 99494 and E/M codes may be used.
    • Psychotherapy codes 90832, 90834, 90837, 90853 may not be used by the same practitioner for the same beneficiary in same month that episode bundles are billed.
    • Rates do not include medications, as they are reimbursed under Medicare Part B or D or toxicology testing that is billed under CLFS.
    • Provider must be licensed in the jurisdiction/location of the patient.
    • The codes are not restricted to use by addiction specialists.
    • Additional telehealth services may be requested before February 10, 2020 for consideration for the following calendar year.
    • The rule notes the prior removal of geographic limitations for telehealth services for SUD or co-occurring mental health disorders.
    • The SUPPORT ACT permits services to be furnished at any originating site, including the patient’s home, and requires that no originating site facility fee is permitted when the individual’s home is the originating site.
    • OTP services are not considered physician/practitioner services, and as such may not bill these codes. Instead, services are covered through OTP bundled rates.

NABH will closely monitor and work with CMS and other stakeholders in the implementation of this benefit and provide updates to NABH members as necessary.

If you have questions, please contact Sarah Wattenberg, NABH’s director of quality and addiction services.
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NABH Issue Brief: CMS Releases Guidance on IMDs Providing Treatment to Medicaid Beneficiaries with At Least One SUD

CMS Releases Guidance on IMDs Providing Treatment to Medicaid Beneficiaries with At Least One SUD

The Centers for Medicare & Medicaid Services (CMS) on Wednesday released guidance to state Medicaid directors that clarifies how section 5052 of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patient and Communities (SUPPORT) Act permits institutions for mental diseases (IMDs) to provide treatment to Medicaid beneficiaries with at least one substance use disorder (SUD).

NABH was a driving force behind section 5052 becoming law and the NABH team has talked with CMS staff about the law’s implementation.

The guidance from CMS covers five key areas: requirements for beneficiaries, requirements for IMDs, requirements for states, maintenance of effort, and interaction with existing IMD policies. This NABH Issue Brief provides a summary of each of those areas.

Requirements for Beneficiaries

An eligible individual for section 5052 (the new IMD authority) is a person who is:

  • a Medicaid enrollee,
  • between the ages of 21 and 64,
  • residing in an IMD primarily to receive withdrawal management or SUD treatment services,
  • diagnosed with at least one SUD, and
  • in an IMD primarily to receive treatment for a SUD (SUD must be the primary diagnosis).

Requirements for IMDs

Eligible IMDs must follow reliable, evidence-based practices and make available at least two forms of medication as part of medication-assisted treatment (MAT). The two drugs may be offered on site upon request or furnished off site by a qualified provider in the community that has an arrangement with the IMD. IMDs “should also offer behavioral health services alongside MAT,” CMS noted.

Requirements for States

States are required to:

  • ensure placement in an IMD will allow the beneficiary to successful transition to the community;
  • ensure that eligible IMDs provide services at lower levels of clinical intensity or establish relationships with providers offering those services;
  • notify CMS how it will ensure eligible individuals receive appropriate evidence-based clinical screening and periodic reassessments to determine the appropriate level of care;
  • cover outpatient SUD treatment services, including early intervention, outpatient services, intensive outpatient services, partial hospitalization, and at least two of the following residential and inpatient levels of care:
    • low-intensity residential services,
    • population specific, high-intensity residential services for adults,
    • medium-intensity residential services for adolescents,
    • high-intensity residential services for adults,
    • high-intensity inpatient services for adolescents,
    • intensive inpatient services withdrawal management for adults, and
    • intensive inpatient services.

Maintenance of Effort

On an annual basis states must:

  • maintain or exceed the level of state and local funding for patients in eligible IMDs as well as services furnished to eligible individuals in outpatient, community-based settings;
  • report the total state and local expenditures, excluding the state share of Medicaid expenditures, for:
    • items and services provided while a patient in an eligible IMD,
    • outpatient and community-based SUD treatment,
    • evidence-based recovery and support services,
    • clinically-directed therapeutic treatment to facilitate recovery skills, relapse prevention and emotional coping strategies,
    • outpatient MAT, related therapies, and pharmacology,
    • counseling and clinical monitoring,
    • outpatient withdrawal management and related treatment, and
    • routine monitoring of medication adherence.

Interaction with Existing IMD Policies
 
States that add the new IMD authority (Section 5052) may also receive monthly capitation payments paid to managed care plans for beneficiaries age 21 through 64 who receive inpatient treatment in an IMD.

Section 5052 does not prevent states from pursuing or conducting a section 1115 demonstration to improve access to, and the quality of, SUD treatment for eligible populations.

Additional Information

CMS is developing a state plan amendment and maintenance of effort reporting templates to assist states. Click here for specific guidance related to state plan amendment submission procedures, including guidance on developing comprehensive methodologies and bundled rates.

If you have questions, please contact Scott Dziengelski, NABH’s director of policy and regulatory affairs.
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CEO Update | 78

Psych-Appeal Files Class Action Complaint Against Health Care Service Corp. and MCG Health

The firm Psych-Appeal this week filed a class-action complaint in the U.S. District Court for the Northern District of Illinois alleging that Health Care Service Corporation (HCSC)—a mutual legal reserve company and an independent licensee of the Blue Cross and Blue Shield Association—
is denying medically necessary residential mental health treatment based on overly restrictive guidelines that MCG Health developed. HCSC is the fourth largest U.S. health insurer operating through its Blue Cross and Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma, and Texas.

Psych-Appeal affiliates with the nation’s law firms, policy groups, and individuals to curb discrimination against mental illness and to expand access to meaningful treatment. Psych-Appeal filed the complaint, Smith v. Health Care Service Corporation, together with Zuckerman Spaeder LLP and Miner, Barnhill & Galland, P.C., on behalf of HCSC insureds.

“In the mental health context, where regulatory oversight is lax, it is all too easy for insurers to discriminate against patients by denying medically necessary care based on clinical guidelines that reference authoritative sources yet distort or omit their content,” Meiram Bendat, Psych-Appeal founder, co-counsel for the plaintiff, and an NABH consultant, said in a news release about the complaint. “Psych-Appeal is committed to exposing and curbing this insidious practice.”

Earlier this year, a federal court found that United Behavioral Health (UBH operating as Optum) developed and applied clinical guidelines to deny coverage for mental health and substance use treatment to more than 50,000 individuals. That case was also brought by Psych-Appeal and Zuckerman Spaeder.

CMS Analyzes Medicaid Coverage for SUD in New Report

NABH this week sent members an NABH Analysis of the Transformed Medicaid Statistical Information System (T-MSIS) SUD Data Book  that the Centers for Medicare & Medicaid Services (CMS) released on Oct. 24.

The data book is the agency’s first annual report to Congress that is meant to improve analysis of Medicaid coverage and service utilization for individuals with substance use disorders (SUDs). Last year’s Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) required the report.

The NABH Analysis provides an overall summary as well as highlights of the data book’s findings on beneficiaries treated, services/setting, length of stay, and funding mechanisms.

Partnership to Amend CFR 42 Part 2 Submits Comments to SAMHSA

NABH was one of nearly 50 organizations in the Partnership to Amend 42 CFR Part 2 (Partnership) that submitted comments to the Substance Abuse and Mental Health Services Administration (SAMHSA) late last week about the agency’s Confidentiality of SUD Patient Records proposed rule.

The six-page comment letter covers a host of provisions in the proposed rule, including consent requirements, disclosures for payment and healthcare operations, audit and evaluation, and non-Part 2 providers.

“SAMHSA’s proposed change focuses on non-Part 2 providers, and we ask SAMHSA to clarify whether this would also apply to other entities such as health plans, healthcare clearinghouses and business associates that receive information from Part 2 providers for non-treatment purposes,” the letter noted. “For example, a payer entity may receive information for insurance claims, and then create their own records to process and pay the claim. Would these changes also apply to these types of records?”

SAMHSA accepted all comments on the rule until last Friday, Oct. 25.

SAMHSA Announces Awards to Promote Behavioral Health in American Indian/Alaska Native Youth

SAMHSA has announced it will invest total funding of $9.2 million to promote mental and behavioral health among American Indian/Alaska Native (AI/AN) youth through the age of 24 years.

SAMHSA said in an announcement that it expects up to 39 awards, funding programs up to $250,000 per year for five-year projects.

Only federally recognized AI/AN tribes, tribal organizations, Urban Indian Organizations, or consortia of tribes or tribal organizations are eligible to apply.

Reminder: SAMHSA Grant Applications for Integrating Primary and Behavioral Healthcare Due Dec. 10

SAMHSA is accepting applications for fiscal year 2020 Promoting Integration of Primary and Behavioral Healthcare (PIPHC) grants until Tuesday, Dec. 10.

The program’s purpose is to promote full integration and collaboration in clinical practice between primary and behavioral healthcare, support integrated care models and improve the overall wellness and health of adults with serious mental illness or children with serious emotional disturbance, and promote and offer integrated care services related to screening, diagnosis, prevention, and treatment of mental and substance use disorders and co-occurring physical health conditions and chronic diseases.

Register Today for the 2020 NABH Annual Meeting!

Please visit NABH’s Annual Meeting homepage today to view the Schedule At-a-Glance and to register for the meeting.

Also please be sure to make your hotel reservation at the Mandarin Oriental Washington, DC from March 16-18, 2020. We look forward to seeing you next March!

Fact of the Week

Although the proportion of facilities with Assertive Community Treatment (ACT) that offer all the required core services has increased in recent years, such programs remain a minority, and the overall number of facilities with ACT has declined.

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NPRM Part 2 Partnership Comments

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NPRM Part 2 partnership Comments

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